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APPLICATION FOR ENCROACHMENT PERR41T <br /> PLEASE PRINT: <br /> Dater":1,4�_f f, T ,aO I S OFFICE USE ONLY <br /> 10: San Joaquin County JOB# ?3 0 7 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> CA L_1 T C P,A)i A i I EP.6L)I C L VALID -2 -1 S TO 7 / -(� DRIVEWAYS: <br /> (Applicant Marne) STREET e tilede e- &I <br /> _ AREA QUAD 4z5 <br /> 1 Co <br /> 02— E . �19 F6 Y [✓TI f ST TYPE <br /> (Mailing Address) FORMS � <br /> _ � L T-o K-l © � - b 95a-0 -NOTES <br /> (Clty,State,Zip Code) <br /> (Area Code e Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and(or otherwise encroach on County Higi Right or Way on <br /> the. side of • o p z�� g approximately fe mile r�h <br /> °f ��- by performing the following work(description of work): <br /> 0 00 <br /> Work will commence on or about or roximately days. <br /> Le � ��5 <br /> 1,the undersigned,certify that I am the owner of the respective proper()r,or am qualifi d to represent the owner and agree to do the <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> 0 l " <br /> Signature of Applicant a Title IDate <br /> M:ICEWRALB :COCESCLERcALIpU6SV.WKVAASTERp51EKCROACH.kieiTpERMRAPPLICAT]Dt DOC(0?113) ' <br /> 1 <br />